Medical Treatment Guidelines Washington State Department of Labor and Industries Criteria for shoulder surgery AND this has A request may be If the patient has AND the diagnosis is supported by been done appropriate for (if recommended) ↓ ↓ ↓ ↓ ↓ ↓ Surgical Clinical findings Conservative Diagnosis procedure care Subjective Objective Imaging

Rotator cuff repair Full thickness Shoulder pain and Patient may have Conventional x-rays, Not required. rotator cuff tear inability to elevate the weakness with AP, and true lateral (CPT 23410, arm; abduction testing; or axillary view 23412, 23420). AND Tenderness over the May also demonstrate AND Cervical pathology greater tuberosity is atrophy of shoulder and frozen shoulder common in acute musculature; Gadolinium MRI, syndrome have been cases. Ultrasound, or ruled out. Usually has full passive Arthrogram shows range of motion. positive evidence of deficit in rotator cuff.

Rotator cuff repair Partial thickness Pain with active arc Weak or absent Conventional x-rays, Recommend 3-6 rotator cuff repair motion 90-130 abduction. May also AP, and true lateral months: Three CPT 23410, 23412, ° demonstrate atrophy or axillary view months is adequate or 23420) OR AND if treatment has

AND AND been continuous, OR Acromial Pain at night; Impingement Tenderness over Gadolinium MRI, six months if Anterior Syndrome Tenderness over the rotator cuff or anterior Ultrasound, or treatment has been acromioplasty ¹ greater tuberosity is intermittent. acromial area Arthrogram shows (80% of these common in acute (CPT 23130, positive evidence of Treatment must be 23415, 29826). patients will get better cases. AND deficit in rotator cuff. without surgery) ¹. directed toward Positive impingement gaining full ROM, sign and temporary which requires both relief of pain with stretching and anesthetic injection strengthening to (diagnostic injection balance the test). musculature.

Treatment of Shoulder AC joint Pain with marked Marked deformity. Conventional x-rays Recommend at acromioclavicular Separation. functional difficulty. Show Grade III+ least 3 months. dislocation, separation. Most patients with grade III AC acute or chronic dislocations are (CPT 23550). best treated non- operatively.

Partial Post traumatic Pain at AC joint; Tenderness over the Conventional films At least 6 weeks of claviculectomy arthritis of AC joint. aggravation of pain AC joint; Most show either: care directed (includes with shoulder motion or symptomatic patients (a) Post traumatic toward symptom Mumford carrying weight with partial AC join changes of AC relief prior to procedure) separation have a joint, OR surgery. OR positive bone scan (b) Severe DJD of (CPT 23120, Previous Grade I or II AC joint, OR Surgery is not 29824). AND/OR indicated before 6 AC separation. (c) Complete or Pain relief obtained incomplete weeks. with an injection of separation of AC anesthetic for joint. diagnostic therapeutic AND trial. Bone scan is positive for AC joint separation.

¹ Neer, C. S. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. Journal of Bone & Joint Surgery, American Volume. 54(1):41-50, 1972 (Jan.). Reference: Provider Bulletin 02-01; Date Introduced: March 2002. Medical Treatment Guidelines Washington State Department of Labor and Industries Criteria for Shoulder Surgery -- Continued

AND this has been A request may be If the patient has AND the diagnosis is supported by done appropriate for (if recommended) ↓ ↓ ↓ ↓ ↓ ↓ Surgical Clinical findings Diagnosis Conservative care procedure Subjective Objective Imaging

Capsulorrhaphy or Recurrent History of multiple At least one of the Conventional x- None required. Bankart procedure glenohumeral dislocations that following: rays, AP and true dislocations. inhibit activities of lateral or axillary (CPT 23450, daily living. Positive apprehension view. 23455, 29806). findings; OR Injury to the humeral head; OR Documented dislocation under anesthesia.

Tenodesis of long Incomplete tear or Complaint of more Partial thickness tears Same as that None required head of biceps raying of the than “normal” do not have the required to rule out proximal biceps amount of pain that classical appearance of full thickness (CPT 23430). tendon. does not resolve ruptured muscle. rotator cuff tear: Consideration of with attempt to use The diagnosis of Conventional x- tenodesis should arm. fraying is usually rays, AP, and true include the identified at the Pain and function lateral or axillary following: time fails to follow view Patient should be a of acromioplasty normal course of young adult; or rotator cuff repair recovery. AND Not recommended so may require as an independent Gadolinium MRI, retrospective review. stand alone Ultrasound, or procedure. Arthrogram shows

There must be positive evidence evidence of an of deficit in rotator incomplete tear. cuff.

Tenodesis of long head of biceps Complete tear of Pain, weakness, Classical appearance Not required. Surgery almost never the proximal and deformity. of ruptured muscle. considered in full (CPT 23430). biceps tendon. thickness ruptures.

Reinsertion of Distal rupture of All should be repaired within 2-3 weeks of injury or diagnosis. A diagnosis is made when the ruptured biceps the biceps tendon. physician cannot palpate the insertion of the tendon at the patient’s antecubital fossa. Surgery is tendon not indicated if 3 or more months have elapsed.

(CPT 24342).

Diagnostic Shoulder Most orthopedic surgeons can generally determine the diagnosis through examination and arthroscopy arthroscopy for imaging studies alone. Diagnostic arthroscopy should be limited to cases where imaging is diagnostic inconclusive and acute pain or functional limitation continues despite conservative care. (CPT 29805). purposes. Shoulder arthroscopy should be performed in the outpatient setting. Requests for authorization of this procedure in the inpatient setting will be reviewed by a peer physician.

If a rotator cuff tear is shown to be present following a diagnostic arthroscopy, follow the guidelines for either a full or partial thickness rotator cuff tear.